Macomb ISD Dental Benefits Plan · Macomb ISD Dental Benefits Plan Transportation The...
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PO Box 610 Southfield, Ml 48037 248-901-3705 Macomb ISD Dental Benefits Plan Transportation The Plan-at-a-Glance PPO Networks: ADN Dental Network, Michi an Dental Plan, DenteMax Maximum Benefits January 1 st through December 31 st Annual Maximum $1000.00 per eligible individual for covered class I, II and Ill seNices. Lifetime Ortho Maximum $1000.00 per eligible individual for covered class IV seNices Class I Preventive Services - 100% Routine Oral Examination Twice per plan year Cleaning (Prophylaxis & Periodontal Maintenance) Twice per plan year Topical Application of Fluoride Twice per plan year, to age 19 Bitewing X-Rays Twice per plan year Full -Mouth Series or Panoramic X-Rays Once per 36 months All Other X-Rays Space Maintainers Once per area per lifetime, up to age 19 Emergency Palliative Treatment Sealants*** Once per 1 si, 2 nd permanent molars, per 36 months, to age 19 Class II Restorative Services - 50% Routine Oral Examination Composite and Amalgam fillings Root Canal Therapy Cleaning (Prophylaxis & Periodontal Maintenance) Periodontal Root Planing Periodontal Surgery Oral Surgery and Extractions General Anesthesia or IV Sedation Twice per plan year Once per tooth surface per 24 months Twice per plan year Once per quadrant per 24 months Once per quadrant per 36 months With covered Oral Surgery or medically necessary Class Ill Major Services - 50% Inlay, Onlay, Crowns Once per tooth per 60 months Complete and Partial Removable Dentures Once per arch per 60 months Fixed Partial Dentures (Bridges) Once per area per 60 months Addition of Teeth to Partial Dentures Denture Reline or Rebase Once per 24 months, per arch Denture Repair or Adjustment Class IV Orthodontic Services - 50% Limited and lnterceptive Treatment Removable and Fixed Appliance Therapy, to age 19 Comprehensive Treatment Fixed Appliance Therapy, to age 19 Not Covered Implants Occlusal Guards TMJ/TMD Treatment Cosmetic Treatment *** Sealants - In Network 100%, Out of Network $20.00 per tooth . Deductible -None Missing Tooth Clause - Yes 12 Month Billing Limitation Waiting Periods - None COB - Standard **Prosthetics are considered on delivery date **Note - Quotes of benefits do not constitute a guarantee of payment. Covered benefits may have limitations or exclusions affecting plan payment. Refer to plan booklet for additional coverage details and limitation. Predetermination is strongly encouraged for all non-emergency dental treatment exceeding $200.00 in charges. The treatment plan should be submitted to ADN prior to beginning any treatment.
Transcript of Macomb ISD Dental Benefits Plan · Macomb ISD Dental Benefits Plan Transportation The...
PO Box 610 Southfield, Ml 48037
248-901-3705
Macomb ISD Dental Benefits Plan Transportation
The Plan-at-a-Glance PPO Networks: ADN Dental Network, Michi an Dental Plan, DenteMax Maximum Benefits January 1st through December 31 st
Annual Maximum $1000.00 per eligible individual for covered class I, II and Ill seNices. Lifetime Ortho Maximum $1000.00 per eligible individual for covered class IV seNices
Class I Preventive Services - 100%
Routine Oral Examination Twice per plan year Cleaning (Prophylaxis & Periodontal Maintenance) Twice per plan year Topical Application of Fluoride Twice per plan year, to age 19 Bitewing X-Rays Twice per plan year Full -Mouth Series or Panoramic X-Rays Once per 36 months All Other X-Rays Space Maintainers Once per area per lifetime, up to age 19 Emergency Palliative Treatment Sealants*** Once per 1 si, 2nd permanent molars, per 36 months, to age 19
Class II Restorative Services - 50% Routine Oral Examination Composite and Amalgam fillings Root Canal Therapy Cleaning (Prophylaxis & Periodontal Maintenance) Periodontal Root Planing Periodontal Surgery Oral Surgery and Extractions General Anesthesia or IV Sedation
Twice per plan year Once per tooth surface per 24 months
Twice per plan year Once per quadrant per 24 months Once per quadrant per 36 months
With covered Oral Surgery or medically necessary
Class Ill Major Services - 50%
Inlay, Onlay, Crowns Once per tooth per 60 months Complete and Partial Removable Dentures Once per arch per 60 months Fixed Partial Dentures (Bridges) Once per area per 60 months Addition of Teeth to Partial Dentures Denture Reline or Rebase Once per 24 months, per arch Denture Repair or Adjustment
Class IV Orthodontic Services - 50%
Limited and lnterceptive Treatment Removable and Fixed Appliance Therapy, to age 19 Comprehensive Treatment Fixed Appliance Therapy, to age 19
Not Covered Implants Occlusal Guards TMJ/TMD Treatment Cosmetic Treatment *** Sealants - In Network 100%, Out of Network $20.00 per tooth .
Deductible -None Missing Tooth Clause - Yes 12 Month Billing Limitation Waiting Periods - None COB - Standard **Prosthetics are considered on delivery date
**Note - Quotes of benefits do not constitute a guarantee of payment. Covered benefits may have limitations or exclusions affecting plan payment. Refer to plan booklet for additional coverage details and limitation. Predetermination is strongly encouraged for all non-emergency dental treatment exceeding $200.00 in charges. The treatment plan should be submitted to ADN prior to beginning any treatment.
PO Box 610 Southfield, Ml 48037
248-901-3705
Macomb ISD Dental Benefits Plan Operators
The Plan-at-a-Glance PPO Networks: ADN Dental Network, Michi an Dental Plan, DenteMax Maximum Benefits January 1st through December 31 st
Annual Maximum $ 750.00 per eligible individual for covered class I, II and Ill seNices. Lifetime Ortho Maximum $1000.00 per eligible individual for covered class IV seNices
Class I Preventive Services - 100%
Routine Oral Examination Twice per plan year Cleaning (Prophylaxis & Periodontal Maintenance) Twice per plan year Topical Application of Fluoride Twice per plan year, to age 19 Bitewing X-Rays Twice per plan year Full -Mouth Series or Panoramic X-Rays Once per 36 months All Other X-Rays Space Maintainers Once per area per lifetime, up to age 19 Emergency Palliative Treatment Sealants*** Once per 1 si, 2nd permanent molars, per 36 months, to age 19
Class II Restorative Services - 50% Routine Oral Examination Composite and Amalgam fillings Root Canal Therapy Cleaning (Prophylaxis & Periodontal Maintenance) Periodontal Root Planing Periodontal Surgery Oral Surgery and Extractions General Anesthesia or IV Sedation
Twice per plan year Once per tooth surface, per 24 months
Twice per plan year Once per quadrant per 24 months Once per quadrant per 36 months
With covered Oral Surgery or medically necessary
Class Ill Major Services - 50%
Inlay, Onlay, Crowns Once per tooth per 60 months Complete and Partial Removable Dentures Once per arch per 60 months Fixed Partial Dentures (Bridges) Once per area per 60 months Addition of Teeth to Partial Dentures Denture Reline or Rebase Once per 24 months, per arch Denture Repair or Adjustment
Class IV Orthodontic Services - 50%
Limited and lnterceptive Treatment Comprehensive Treatment
Removable and Fixed Appliance Therapy, up to age 19 Fixed Appliance Therapy, up to age 19
Not Covered Implants Occlusal Guards TMJ/TMD Treatment Cosmetic Treatment *** Sealants - In Network 100%, Out of Network $20.00
Deductible -None Missing Tooth Clause - Yes 12 Month Billing Limitation Waiting Periods - None COB - Standard **Prosthetics are considered on delivery date
**Note - Quotes of benefits do not constitute a guarantee of payment. Covered benefits may have limitations or exclusions affecting plan payment. Refer to plan booklet for additional coverage details and limitation. Predetermination is strongly encouraged for all non-emergency dental treatment exceeding $200.00 in charges. The treatment plan should be submitted to ADN prior to beginning any treatment.
PO Box 610 Southfield, Ml 48037
248-901-3705
Macomb ISD Dental Benefits Plan Other - Non Bargaining
The Plan-at-a-Glance PPO Networks: ADN Dental Network, Michi an Dental Plan, DenteMax Maximum Benefits January 1st through December 31 st
Annual Maximum $1000.00 per eligible individual for covered class I, II and Ill seNices. Lifetime Ortho Maximum $2000.00 per eligible individual for covered class IV seNices
Class I Preventive Services - 100%
Routine Oral Examination Twice per plan year Cleaning (Prophylaxis & Periodontal Maintenance) Twice per plan year Topical Application of Fluoride Twice per plan year, to age 19 Bitewing X-Rays Twice per plan year Full -Mouth Series or Panoramic X-Rays Once per 36 months All Other X-Rays Space Maintainers Once per area per lifetime, up to age 19 Emergency Palliative Treatment Sealants*** Once per 1 si, 2nd permanent molars, per 36 months, to age 19
Class II Restorative Services - 50% Routine Oral Examination Composite and Amalgam fillings Root Canal Therapy Cleaning (Prophylaxis & Periodontal Maintenance) Periodontal Root Planing Periodontal Surgery Oral Surgery and Extractions General Anesthesia or IV Sedation
Twice per plan year Once per tooth surface per 24 months
Twice per plan year Once per quadrant per 24 months Once pre quadrant per 36 months
With covered Oral Surgery or medically necessary
Class Ill Major Services - 50%
Inlay, Onlay, Crowns Once per tooth per 60 months Complete and Partial Removable Dentures Once per arch per 60 months Fixed Partial Dentures (Bridges) Once per area per 60 months Addition of Teeth to Partial Dentures Denture Reline or Rebase Once per 24 months, per arch Denture Repair or Adjustment
Class IV Orthodontic Services - 50%
Limited and lnterceptive Treatment Removable and Fixed Appliance Therapy, to age 19 Comprehensive Treatment Fixed Appliance Therapy, to age 19
Not Covered Implants Occlusal Guards TMJ/TMD Treatment Cosmetic Treatment *** Sealants - In Network 100%, Out of Network $20.00 per tooth
Deductible -None Missing Tooth Clause - Yes 12 Month Billing Limitation Waiting Periods - None COB - Standard **Prosthetics are considered on delivery date
**Note - Quotes of benefits do not constitute a guarantee of payment. Covered benefits may have limitations or exclusions affecting plan payment. Refer to plan booklet for additional coverage details and limitation. Predetermination is strongly encouraged for all non-emergency dental treatment exceeding $200.00 in charges. The treatment plan should be submitted to ADN prior to beginning any treatment.
PO Box 610 Southfield, Ml 48037
248-901-3705
Macomb ISD Dental Benefits Plan Administration
The Plan-at-a-Glance PPO Networks: ADN Dental Network, Michi an Dental Plan, DenteMax Maximum Benefits January 1st through December 31 st
Annual Maximum $1000.00 per eligible individual for covered class I, II and Ill seNices. Lifetime Ortho Maximum $2000.00 per eligible individual for covered class IV seNices
Class I Preventive Services - 100%
Routine Oral Examination Twice per plan year Cleaning (Prophylaxis & Periodontal Maintenance) Twice per plan year Topical Application of Fluoride Twice per plan year, to age 19 Bitewing X-Rays Twice per plan year Full -Mouth Series or Panoramic X-Rays Once per 36 months All Other X-Rays Space Maintainers Once per area per lifetime, up to age 19 Emergency Palliative Treatment Sealants*** Once per 1 si, 2nd permanent molars, per 36 months, to age 19
Class II Restorative Services - 50% Routine Oral Examination Composite and Amalgam fillings Root Canal Therapy Cleaning (Prophylaxis & Periodontal Maintenance) Periodontal Root Planing Periodontal Surgery Oral Surgery and Extractions General Anesthesia or IV Sedation
Twice per plan year Once per tooth surface per 24 months
Twice per plan year Once per quadrant per 24 months Once pre quadrant per 36 months
With covered Oral Surgery or medically necessary
Class Ill Major Services - 50%
Inlay, Onlay, Crowns Once per tooth per 60 months Complete and Partial Removable Dentures Once per arch per 60 months Fixed Partial Dentures (Bridges) Once per area per 60 months Addition of Teeth to Partial Dentures Denture Reline or Rebase Once per 24 months, per arch Denture Repair or Adjustment
Class IV Orthodontic Services - 50%
Limited and lnterceptive Treatment Removable and Fixed Appliance Therapy, to age 19 Comprehensive Treatment Fixed Appliance Therapy, to age 19
Not Covered Implants Occlusal Guards TMJ/TMD Treatment Cosmetic Treatment *** Sealants - In Network 100%, Out of Network $20.00 per tooth
Deductible -None Missing Tooth Clause - Yes 12 Month Billing Limitation Waiting Periods - None COB - Standard **Prosthetics are considered on delivery date
**Note - Quotes of benefits do not constitute a guarantee of payment. Covered benefits may have limitations or exclusions affecting plan payment. Refer to plan booklet for additional coverage details and limitation. Predetermination is strongly encouraged for all non-emergency dental treatment exceeding $200.00 in charges. The treatment plan should be submitted to ADN prior to beginning any treatment.
PO Box 610 Southfield, Ml 48037
248-901-3705
Macomb ISD Dental Benefits Plan ParaProfessional
The Plan-at-a-Glance PPO Networks: ADN Dental Network, Michi an Dental Plan, DenteMax Maximum Benefits January 1st through December 31 st
Annual Maximum $ 750.00 per eligible individual for covered class I, II and Ill seNices. Lifetime Ortho Maximum $1000.00 per eligible individual for covered class IV seNices
Class I Preventive Services - 100%
Routine Oral Examination Twice per plan year Cleaning (Prophylaxis & Periodontal Maintenance) Twice per plan year Topical Application of Fluoride Twice per plan year, to age 19 Bitewing X-Rays Twice per plan year Full -Mouth Series or Panoramic X-Rays Once per 36 months All Other X-Rays Space Maintainers Once per area per lifetime, up to age 19 Emergency Palliative Treatment Sealants*** Once per 1 si, 2nd permanent molars, per 36 months, to age 19
Class II Restorative Services - 50% Routine Oral Examination Composite and Amalgam fillings Root Canal Therapy Cleaning (Prophylaxis & Periodontal Maintenance) Periodontal Root Planing Periodontal Surgery Oral Surgery and Extractions General Anesthesia or IV Sedation
Twice per plan year Once per tooth surface, per 24 months
Twice per plan year Once per quadrant per 24 months Once per quadrant per 36 months
With covered Oral Surgery or medically necessary
Class Ill Major Services - 50%
Inlay, Onlay, Crowns Once per tooth per 60 months Complete and Partial Removable Dentures Once per arch per 60 months Fixed Partial Dentures (Bridges) Once per area per 60 months Addition of Teeth to Partial Dentures Denture Reline or Rebase Once per 24 months, per arch Denture Repair or Adjustment
Class IV Orthodontic Services - 50%
Limited and lnterceptive Treatment Comprehensive Treatment
Removable and Fixed Appliance Therapy, up to age 19 Fixed Appliance Therapy, up to age 19
Not Covered Implants Occlusal Guards TMJ/TMD Treatment Cosmetic Treatment *** Sealants - In Network 100%, Out of Network $20.00
Deductible -None Missing Tooth Clause - Yes 12 Month Billing Limitation Waiting Periods - None COB - Standard **Prosthetics are considered on delivery date
**Note - Quotes of benefits do not constitute a guarantee of payment. Covered benefits may have limitations or exclusions affecting plan payment. Refer to plan booklet for additional coverage details and limitation. Predetermination is strongly encouraged for all non-emergency dental treatment exceeding $200.00 in charges. The treatment plan should be submitted to ADN prior to beginning any treatment.
PO Box 610 Southfield, Ml 48037
248-901-3705
Macomb ISD Dental Benefits Plan Professional
The Plan-at-a-Glance PPO Networks: ADN Dental Network, Michi an Dental Plan, DenteMax Maximum Benefits January 1st through December 31 st
Annual Maximum $ 750.00 per eligible individual for covered class I, II and Ill seNices. Lifetime Ortho Maximum $1000.00 per eligible individual for covered class IV seNices
Class I Preventive Services - 100%
Routine Oral Examination Twice per plan year Cleaning (Prophylaxis & Periodontal Maintenance) Twice per plan year Topical Application of Fluoride Twice per plan year, to age 19 Bitewing X-Rays Twice per plan year Full -Mouth Series or Panoramic X-Rays Once per 36 months All Other X-Rays Space Maintainers Once per area per lifetime, up to age 19 Emergency Palliative Treatment Sealants*** Once per 1 si, 2nd permanent molars, per 36 months, to age 19
Class II Restorative Services - 50% Routine Oral Examination Composite and Amalgam fillings Root Canal Therapy Cleaning (Prophylaxis & Periodontal Maintenance) Periodontal Root Planing Periodontal Surgery Oral Surgery and Extractions General Anesthesia or IV Sedation
Twice per plan year Once per tooth surface, per 24 months
Twice per plan year Once per quadrant per 24 months Once per quadrant per 36 months
With covered Oral Surgery or medically necessary
Class Ill Major Services - 50%
Inlay, Onlay, Crowns Once per tooth per 60 months Complete and Partial Removable Dentures Once per arch per 60 months Fixed Partial Dentures (Bridges) Once per area per 60 months Addition of Teeth to Partial Dentures Denture Reline or Rebase Once per 24 months, per arch Denture Repair or Adjustment
Class IV Orthodontic Services - 50%
Limited and lnterceptive Treatment Comprehensive Treatment
Removable and Fixed Appliance Therapy, up to age 19 Fixed Appliance Therapy, up to age 19
Not Covered Implants Occlusal Guards TMJ/TMD Treatment Cosmetic Treatment *** Sealants - In Network 100%, Out of Network $20.00
Deductible -None Missing Tooth Clause - Yes 12 Month Billing Limitation Waiting Periods - None COB - Standard **Prosthetics are considered on delivery date
**Note - Quotes of benefits do not constitute a guarantee of payment. Covered benefits may have limitations or exclusions affecting plan payment. Refer to plan booklet for additional coverage details and limitation. Predetermination is strongly encouraged for all non-emergency dental treatment exceeding $200.00 in charges. The treatment plan should be submitted to ADN prior to beginning any treatment.
PO Box 610 Southfield, Ml 48037
248-901-3705
Macomb ISD Dental Benefits Plan Administrative Support
The Plan-at-a-Glance PPO Networks: ADN Dental Network, Michi an Dental Plan, DenteMax Maximum Benefits January 1st through December 31 st
Annual Maximum $1000.00 per eligible individual for covered class I, II and Ill seNices. Lifetime Ortho Maximum $1000.00 per eligible individual for covered class IV seNices
Class I Preventive Services - 100%
Routine Oral Examination Twice per plan year Cleaning (Prophylaxis & Periodontal Maintenance) Twice per plan year Topical Application of Fluoride Twice per plan year, to age 19 Bitewing X-Rays Twice per plan year Full -Mouth Series or Panoramic X-Rays Once per 36 months All Other X-Rays Space Maintainers Once per area per lifetime, up to age 19 Emergency Palliative Treatment Sealants*** Once per 1 si, 2nd permanent molars, per 36 months, to age 19
Class II Restorative Services - 50% Routine Oral Examination Composite and Amalgam fillings Root Canal Therapy Cleaning (Prophylaxis & Periodontal Maintenance) Periodontal Root Planing Periodontal Surgery Oral Surgery and Extractions General Anesthesia or IV Sedation
Twice per plan year Once per tooth surface per 24 months
Twice per plan year Once per quadrant per 24 months Once per quadrant per 36 months
With covered Oral Surgery or medically necessary
Class Ill Major Services - 50%
Inlay, Onlay, Crowns Once per tooth per 60 months Complete and Partial Removable Dentures Once per arch per 60 months Fixed Partial Dentures (Bridges) Once per area per 60 months Addition of Teeth to Partial Dentures Denture Reline or Rebase Once per 24 months, per arch Denture Repair or Adjustment
Class IV Orthodontic Services - 50%
Limited and lnterceptive Treatment Removable and Fixed Appliance Therapy, to age 19 Comprehensive Treatment Fixed Appliance Therapy, to age 19
Not Covered Implants Occlusal Guards TMJ/TMD Treatment Cosmetic Treatment *** Sealants - In Network 100%, Out of Network $20.00 per tooth .
Deductible -None Missing Tooth Clause - Yes 12 Month Billing Limitation Waiting Periods - None COB - Standard **Prosthetics are considered on delivery date
**Note - Quotes of benefits do not constitute a guarantee of payment. Covered benefits may have limitations or exclusions affecting plan payment. Refer to plan booklet for additional coverage details and limitation. Predetermination is strongly encouraged for all non-emergency dental treatment exceeding $200.00 in charges. The treatment plan should be submitted to ADN prior to beginning any treatment.
PO Box 610 Southfield, Ml 48037
248-901-3705
Macomb ISD Dental Benefits Plan Data Technicians
The Plan-at-a-Glance PPO Networks: ADN Dental Network, Michi an Dental Plan, DenteMax Maximum Benefits January 1st through December 31 st
Annual Maximum $1000.00 per eligible individual for covered class I, II and Ill seNices. Lifetime Ortho Maximum $1000.00 per eligible individual for covered class IV seNices
Class I Preventive Services - 100%
Routine Oral Examination Twice per plan year Cleaning (Prophylaxis & Periodontal Maintenance) Twice per plan year Topical Application of Fluoride Twice per plan year, to age 19 Bitewing X-Rays Twice per plan year Full -Mouth Series or Panoramic X-Rays Once per 36 months All Other X-Rays Space Maintainers Once per area per lifetime, up to age 19 Emergency Palliative Treatment Sealants*** Once per 1 si, 2nd permanent molars, per 36 months, to age 19
Class II Restorative Services - 50% Routine Oral Examination Composite and Amalgam fillings Root Canal Therapy Cleaning (Prophylaxis & Periodontal Maintenance) Periodontal Root Planing Periodontal Surgery Oral Surgery and Extractions General Anesthesia or IV Sedation
Twice per plan year Once per tooth surface per 24 months
Twice per plan year Once per quadrant per 24 months Once per quadrant per 36 months
With covered Oral Surgery or medically necessary
Class Ill Major Services - 50%
Inlay, Onlay, Crowns Once per tooth per 60 months Complete and Partial Removable Dentures Once per arch per 60 months Fixed Partial Dentures (Bridges) Once per area per 60 months Addition of Teeth to Partial Dentures Denture Reline or Rebase Once per 24 months, per arch Denture Repair or Adjustment
Class IV Orthodontic Services - 50%
Limited and lnterceptive Treatment Removable and Fixed Appliance Therapy, to age 19 Comprehensive Treatment Fixed Appliance Therapy, to age 19
Not Covered Implants Occlusal Guards TMJ/TMD Treatment Cosmetic Treatment *** Sealants - In Network 100%, Out of Network $20.00 per tooth .
Deductible -None Missing Tooth Clause - Yes 12 Month Billing Limitation Waiting Periods - None COB - Standard **Prosthetics are considered on delivery date
**Note - Quotes of benefits do not constitute a guarantee of payment. Covered benefits may have limitations or exclusions affecting plan payment. Refer to plan booklet for additional coverage details and limitation. Predetermination is strongly encouraged for all non-emergency dental treatment exceeding $200.00 in charges. The treatment plan should be submitted to ADN prior to beginning any treatment.
